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  1. 1. Ensayo clínico
  2. 2. Documentación de rutina
  3. 3. Estudio de registro / cohorte
  4. 4. Seguro de calidad
  5. 5. Estándar de datos
    1. 5.1. Elementos de datos comunes
      1. Estándar lanzado
      1. Borrador de estándar
      1. Estándar obsoleto
    1. 5.2. Puntuaciones e instrumentos
      1. Estándar lanzado
      1. Borrador de estándar
      1. Estándar obsoleto
    1. 5.3. Clasificación
      1. Estándar lanzado
      1. Borrador de estándar
      1. Estándar obsoleto
    1. 5.4. Arquetipos
      1. Publicado
  6. 6. Resultado reportado por el paciente
  7. 7. Especialidad médica
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APGAR Score (EHR Archetype) - openEHR-EHR-OBSERVATION.apgar.v1

- 8/7/17 - 1 form, 1 itemgroup, 14 items, 9 languages
Itemgroup: openEHR-EHR-OBSERVATION.apgar.v1
Derived from www.openehr.org . Allows recording of an assessment of the state of a neonate explicitly as 1, 2, 3, 5 and/or 10 minute events after birth, plus additional events as required. Usual practice is to document the Apgar score at 1 and 5 minutes; further scores can be recorded as clinically indicated. It is possible to record the Apgar score at any time after birth using this archetype. Common clinical practice is to record all 5 parameters plus the total, however this archetype allows any partial information to be recorded, if that is all that is available eg from historical data. If the total is to be calculated, it is necessary for all 5 ordinal values to be recorded. The total is the sum of the five ordinal values (min 0, max 10). It is recognised that mnemonic learning aid for APGAR is commonly taught. For example, in English: A for Appearance (skin color), P for Pulse (heart rate), G for Grimace (reflex irritability), A for Activity (muscle tone), and R for Respiration. As this is not universally applicable for all languages, it is suggested that this mnemonic can be applied by renaming the data elements within templates if desired for a specific clinical scenario.

Montreal Cognitive Assessment (MoCA) - MoCA

- 28/11/17 - 1 form, 10 itemgroups, 30 items, 7 languages
Itemgroups: Alternating Trail Making, Visuoconstructional Skills, Naming, Memory, Attention, Language, Abstraction, Delayed Recall, Orientation, MoCA
https://en.wikipedia.org/wiki/Montreal_Cognitive_Assessment

Modified Rankin Scale

- 28/11/17 - 1 form, 1 itemgroup, 1 item, 4 languages
Itemgroup: Modified Rankin Scale
https://en.wikipedia.org/wiki/Modified_Rankin_Scale The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It has become the most widely used clinical outcome measure for stroke clinical trials.

Barthel-Index

- 23/11/17 - 1 form, 1 itemgroup, 11 items, 4 languages
Itemgroup: Barthel Index
https://de.wikipedia.org/wiki/Barthel-Index

Center for Epidemiologic Studies Depression Scale – Revised (CESD-R)

- 27/9/21 - 1 form, 1 itemgroup, 20 items, 1 language
Itemgroup: Symptoms of depression past week
The Center for Epidemiologic Studies Depression Scale (CESD) was created in 1977 by Laurie Radloff, and revised in 2004 by William Eaton and others. The 20 items in CESD-R scale measure symptoms of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual, fifth edition. References: Eaton WW, Muntaner C, Smith C, Tien A, Ybarra M. Center for Epidemiologic Studies Depression Scale: Review and revision (CESD and CESD-R). In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment. 3rd ed. Mahwah, NJ: Lawrence Erlbaum; 2004:363-377. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1:385-401. http://cesd-r.com/

Clinical risk index for babies II (CRIB II) score

- 27/9/21 - 1 form, 1 itemgroup, 7 items, 1 language
Itemgroup: CRIB II
The five-item CRIB II score is an update of the with clinical risk index for babies (CRIB) score, a risk-adjustment instrument widely used in neonatal intensive care. Parry, G., Tucker, J., Tarnow-Mordi, W., & UK Neonatal Staffing Study Collaborative Group. (2003). CRIB II: an update of the clinical risk index for babies score. The Lancet, 361(9371), 1789-1791.

QMMI score

- 27/9/21 - 1 form, 1 itemgroup, 12 items, 1 language
Itemgroup: QMMI score
In the context of the Quality Measurement and Management Initiative (QMMI) Coronary Revascularization Project, this "clinical prediction rule for in-hospital major adverse outcomes, defined as death, renal failure, reinfarction, cardiac arrest, cerebrovascular accident, or coma, in patients who underwent coronary artery bypass grafting (CABG)", was developed. Reference: Fortescue, E. B., Kahn, K., & Bates, D. W. (2001). Development and validation of a clinical prediction rule for major adverse outcomes in coronary bypass grafting. The American journal of cardiology, 88(11), 1251-1258.

GAP index and staging system

- 27/9/21 - 1 form, 1 itemgroup, 5 items, 1 language
Itemgroup: GAP index and staging system
The GAP index and staging system is a multidimensional prognostic staging system using commonly measured clinical and physiologic variables to predict mortality in patients with idiopathic pulmonary fibrosis (IPF). Reference: Ley, B., Ryerson, C. J., Vittinghoff, E., Ryu, J. H., Tomassetti, S., Lee, J. S., ... & King, T. E. (2012). A multidimensional index and staging system for idiopathic pulmonary fibrosis. Annals of internal medicine, 156(10), 684-691.

SC Childhood Cohen’s Scale - SC Childhood

- 20/9/21 - 1 form, 6 itemgroups, 86 items, 1 language
Itemgroups: Childhood, age kindergarten, age 4th -5th grade, age 9th -10th grade, Moving to new residence Childhood Adolescence, Community Ladder
ODM form of Dr. Cohen's Scales. This form contains questions about childhood and adolescence. Forms derived from http://www.psy.cmu.edu/~scohen/scales.html

LEL Cohen’s Scale - LEL LIFE EVENTS CHECKLIST

- 1/10/20 - 1 form, 1 itemgroup, 72 items, 1 language
Itemgroup: life events
ODM form of Dr. Cohen's Scales. The form contains questions about a number of events that commonly happen in people's lives. More information: https://www.cmu.edu/dietrich/psychology/stress-immunity-disease-lab/scales/index.html Forms originally derived from http://www.psy.cmu.edu/~scohen/scales.html Source article: Cohen, S., Tyrrell, D. A. J., & Smith, A. P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 606-612. Related articles: Cohen, S., & Williamson, G. (1991). Stress and infectious disease in humans. Psychological Bulletin,109, 5-24. Cohen, S., Tyrrell, D. A. J., & Smith, A. P. (1993). Negative life events, perceived stress, negative affect and susceptibility to the common cold. Journal of Personality and Social Psychology, 64, 131-140.

BMLSS Brief Multidimensional Life Satisfaction Scale (generic)

- 25/6/19 - 1 form, 1 itemgroup, 11 items, 6 languages
Itemgroup: life satisfaction
Questionnaires on the quality of life and spirituality. A project of the Faculty of Health at University Witten/Herdecke. Publication granted by Prof. Dr. Büssing. Source: https://spneeds.uni-wh.de/ Spanish translation: Stefano Vinaccia. Polish translation: Janusz Surzykiewicz. Arabic translation: Dr. Fawwaz Ayoub Momani.

Simplified Pulmonary Embolism Severity Index (sPESI)

- 25/1/18 - 1 form, 1 itemgroup, 7 items, 1 language
Itemgroup: sPESI
The Pulmonary Embolism Severity Index (PESI) estimates the risk of 30-day mortality in patients with acute pulmonary embolism (PE). The simplified PESI has similar prognostic accuracy and clinical utility and greater ease of use compared with the original PESI. Reference: Jiménez, D., Aujesky, D., Moores, L., Gómez, V., Lobo, J. L., Uresandi, F., ... & Yusen, R. D. (2010). Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Archives of internal medicine, 170(15), 1383-1389.

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